Currently, the diagnosis of female sexual dysfunction is based purely on history. Because female sexual dysfunction has always been considered a psychiatric disorder, there are no real diagnostic frameworks available except in the psychiatric literature.
The best listing of female sexual dysfunction disorders is found in the Diagnostic and Statistical Manual of Mental Disorders (Version 4-DSM-IV). The DSM-IV is a manual of mental disorders that has been used in the United States for a great number of years. Unfortunately, sexual therapists and psychiatrists have always carried out the diagnosis of female sexual dysfunction, which is also true of the way erectile dysfunction has been diagnosed in men. Less than a decade ago, over 90% of erectile disorders were considered psychological in origin and, as a consequence, were also found in the DMS-IV. Fortunately, the diagnostic categories in this manual provide an excellent framework when discussing this topic.
The term “sexual dysfunction,” as defined in the DMS-IV, is categorized by a disturbance in the processes that form the sexual response cycle or by pain associated with intercourse. The sexual response cycle is divided into four distinct phases, which were described in 1966 and were used to identify some of the problems that can exist in both the diagnosis and treatment of sexual dysfunction disorders.
The first phase is desire, which involves fantasies about and the desire to have sexual activity. The next phase is the excitement phase, evidenced by vaginal lubrication. The corresponding excitement phase in a man would be the development of an erection. In a woman, the fluid produced in the vagina is a consequence of increased blood flow and not the result of glandular secretions. Blood flow into the pelvis increases during excitement causing congestion throughout the pelvis, but especially in the vagina, uterus and clitoris. This causes the capillaries, the tubes that carry the blood, to become permeable and fluid leaks out of the blood vessels in response to the excitement. Also, muscle tension in the vagina increases as the vaginal tube expands and enlarges in anticipation of penetration.
The next phase is known as the plateau or orgasm phase when the outer part of the vagina dilates or opens and the middle portion constricts. The following phase, known as the orgasmic platform, is when the uterus increases in size as a result of increased blood flow. Also, the clitoris elevates from its natural position and flattens out on the top of the pubic bone or symphysis. This is the bone that one can feel when pushing down just below the abdomen. This phase is analogous to an erection in a man. Although smaller in size, the clitoris is similar in structure to the penis. During orgasm, the blood flow peaks and muscles in the outer third of the vagina and the uterus contract in a regular rhythm with high levels of muscle tension.
Finally, there is the resolution phase, when blood flow returns to normal and muscle tension and tightness dramatically decrease. It was previously thought that muscle tension and blood flow would decrease at a much slower rate if orgasm had not been achieved, which would create sexual tension but this has never been proven physiologically.
The psychiatric diagnoses always differentiate between a lifelong condition or an acquired one and whether the condition occurs always or only in certain situations. An example of a lifelong condition is one resulting from sexual trauma that keeps a woman from ever being able to tolerate penetration. An example of an acquired dysfunction is one where a woman has just started on birth control pills. Previously, she had an excellent sexual relationship and now experiences a sudden onset of problems due to lack of lubrication.
Another diagnostic sub-type is when the problem is due to a psychological problem or combination of problems, such as substance abuse, spousal abuse, or abuse from a sexual partner.
Hypoactive Sexual Desire Disorder
The most common female sexual disorder, called hypoactive sexual desire disorder, occurs when there is an absence of sexual fantasies or desire for sexual activity. Criteria necessary for this diagnosis include persistently deficient or absent sexual fantasies and/or desire for sexual activity. The judgment of whether this deficiency is present or absent is made by the clinician taking into account factors that affect sexual functioning such as age and the context of the person’s life. In order for this to be considered a sexual dysfunction, the lack of interest in sex must cause marked distress or interpersonal difficulty, cannot be accounted for by another diagnosis, and should not be due exclusively to the affects of drug abuse or such general medical conditions as diabetes or kidney failure.
Obviously, a 90 year-old woman would not be expected to have tremendous sexual desire and we would probably not make the diagnosis of sexual dysfunction. Additionally, a single parent with two jobs and a very full life would probably not have a great deal of sexual desire because she is exhausted at the end of the day.
Treatment for hypoactive sexual desire disorder is twofold. First, it is important to make a correct diagnosis. When we are comfortable that there is no organic cause and we have treated any severe medical conditions such as diabetes or heart disease, we will then discuss and rule out the possibility of any interpersonal difficulty with a partner. Once diagnosed, this condition is very amenable to treatment with hormone supplements, especially in women with a documented low level of hormones, or with appropriate sexual therapy. Sexual therapy plays a very important role in this type of disorder because frequently the solution may be as simple as informing a patient’s partner that she is not interested. Hormone treatments are covered extensively elsewhere.
Sexual Aversion Disorder
Sexual Aversion Disorder is the avoidance of genital sexual contact with a sexual partner. This diagnosis requires that the disturbance causes marked distress or interpersonal difficulties and that the affected individual reports anxiety, fear or disgust when confronted by a sexual opportunity with a partner. This aversion to genital contact may be focused on a particular aspect of the sexual experience including genital secretions or vaginal penetration. Rarely, some individuals may feel revolted by all sexual stimuli, including kissing and touching, and may experience a severe panic attack when sexual intercourse is initiated. The disorder may be associated with other sexual dysfunctions including painful penetration. These individuals will go to heroic lengths to avoid participating in sexual activity.
This condition generally affects women who have been through some type of sexual crisis such as rape, gang rape, forced sex, or sex with a family member. This disorder is also very common in religious orders as some faiths have very strict rules about sexual activity.
Female Sexual Arousal Disorder
The second most common type of female sexual dysfunction, female sexual arousal disorder, is characterized as a persistent or recurrent inability to obtain or maintain adequate lubrication or swelling response during the excitement phase. As with other diagnoses, this disturbance must cause marked interpersonal difficulties or distress and should not be accounted for by another disorder or by medications. This is the most common sexual disorder seen in postmenopausal women due to a lack of adequate lubrication. Prior to the advent of new medications, this was treated with vaginal lubricants such as K-Y jelly or others that are commercially available. The most common lubricant used, saliva, is probably the most physiologically compatible and the most reasonable. Other lubricants, including K-Y jelly and petroleum-based products like Vaseline, do not correct the uncomfortable feeling but only provide more lubrication.
When this condition is seen in young women, it is almost always related to the side affects from such medications as birth control pills. Diabetes, especially a long-standing case, may cause a decrease in lubrication and may also cause decreased blood flow, which results in a higher risk of developing bacterial and fungal infections in the vagina.
Radiation treatments are another common cause of decreased lubrication. Women who have had radiation treatments for vaginal or pelvic malignancies will often have difficulty with penetration due to dry vaginas. Women that are being treated for breast cancer with anti-estrogens or medications to prevent recurrence of breast cancer such as the drug Tamoxifen may develop a very dry vagina and have difficulty with penetration as well. Decreased lubrication is also seen during breast-feeding and it is not uncommon in postpartum women due to an elevation of the hormone prolactin, which is stimulated by lactation. Interestingly, men who have elevated prolactin levels also lose interest in sex.
The treatment of female sexual arousal disorder is very controversial. Physiologically, the problem is related to decreased blood flow to the pelvic organs so treating the underlying illness can have dramatic affects. For example, poorly controlled diabetes can be treated with a proper diet and medication, which can result in a return to normal lubrication. If hypertension is present, medications used to treat it can be modified or changed. When a hormonal cause can be identified, it is best to start treatment with topical estrogens, and if the testosterone level is low, testosterone cream may be used as well. Oral supplementation of estrogen is indicated in certain situations, but oral estrogen doesn’t always improve vaginal lubrication. In many cases, the addition of a vaginal estriol cream or estrogen ring is helpful.
For people who have had breast cancer and who are adamant about not wanting hormonal treatments, Vitamin E suppositories, which can be obtained in any health food store, are very useful. These provide a non-hormonal way to improve tissue tone in the vagina.
When all other treatments fail, synthetic lubrication may be indicated. Water-soluble lubricants are commercially available and include K-Y jelly and Surgilube. Because they are water-soluble, they generally don’t cause problems. Silicon-based lubricants are satisfactory as well. In contrast, petroleum-based lubricants, such as Vaseline, are sticky, can harbor bacteria, and can degrade rubber products such as condoms Saliva, a natural lubricant, works very well.
Female Orgasmic Disorders
Female Orgasmic Disorder is described as a persistent or recurrent delay or absence of an orgasm following the normal sexual excitement phase. This is an extremely difficult diagnosis to make and, unfortunately, may be much more common than we imagine. This disorder is more difficult to characterize because of the difficulty in documenting the female orgasm. The book, Sex in America, describes a survey in which 29% of women said they always had an orgasm during sex with their primary partner. Forty-four percent of the men in the study thought that their female partner always had an orgasm. By contrast, women in the study were always correct when they guessed whether their male partner had had an orgasm or not.
There has also been a great deal of confusion in the literature about exactly what constitutes an orgasm. The most reliable definition is the known physiology of orgasm – basically a vaginal and uterine contraction secondary to increased blood flow. Whether the orgasm is from clitoral or vaginal stimulation, masturbation, oral sex or other stimulation, the end result is the same.
The group of anti-depressants known as selective serotonin reuptake inhibitors is notorious for inhibiting and preventing orgasm. This is perhaps the most commonly prescribed group of drugs for depression and other related disorders in the United States.
Dyspareunia is genital pain associated with sexual intercourse. The condition is found in both men and women, but it is far more common in women and is considered a female condition. When one discusses pain during vaginal penetration, it is important to characterize exactly where the pain occurs. Pain can be associated with initial penetration or during deep thrusting. The intensity of the pain may be such that intercourse is impossible. Again, before it can be considered a diagnosis, this disturbance must cause marked distress or interpersonal difficulties. The pain should not be that associated with vaginismus or lack of lubrication (both discussed elsewhere), as both of these disorders fall into other classes of disorder.
Excessive side effects from medication or a general medical condition should also be eliminated prior to establishing this diagnosis. General medication conditions that cause painful penetration would include such sexually transmitted diseases as vaginal herpes or bacterial infections. Yeast infections would also fall into this category and are very common in women. Other considerations would include pain at the bottom part of the vagina in the area known as the posterior fourchette. While fairly unusual, this condition can be associated with severe pain during penetration. The diagnosis of dyspareunia is almost always associated with an organic condition and only a careful history and physical examination will discern the exact cause and allow the exact treatment to be recommended.
Vaginismus is defined as the recurrent or persistent involuntary contraction of the perineal muscles surrounding the outer third of the vagina when insertion of any object is attempted, such as a penis, finger or even a tampon. Again, before making this diagnosis, a doctor should ascertain that the disturbance causes marked distress or interpersonal difficulty. Generally, this is the case when a patient comes for help with vaginismus because she’s generally exhausted all obvious options. Vaginismus may be readily apparent on an attempted vaginal examination. It is important to differentiate vaginismus from dyspareunia because the diagnosis is almost always associated with psychiatric problems or a prior history of sexual abuse or sexual trauma. This disorder is almost always found in younger rather than older women and in women with negative attitudes towards sexual intercourse, a history of prior rape, sexual trauma, or even incest. Vaginismus is the most rare of the female sexual dysfunction disorders and is almost always associated with other diagnoses. Vaginismus can affect the perineal muscles as well as the levator muscles, which are the muscles that help hold up the rectum.
It is important to be sure of a vaginismus diagnosis because of its tremendous psychiatric overtones. It’s extremely important that this diagnosis is not made on the basis of history alone but also should be based on physical examination. The classic theory of vaginismus is that a woman will experience severe pain with attempts at penetration of her vagina with either her finger or a tampon and this causes a natural, self-protective, tightening response that prevents penetration at a later time. Unfortunately, this condition causes avoidance behavior that can lead to substantial marital discord, which often ends in divorce. After a careful history and physical examination to determine that there is no obvious organic cause, doctors generally refer these patients and their sexual partners to a sexual therapist. A good sexual therapist can work miracles in these situations.